Healthcare Provider Details

I. General information

NPI: 1396455937
Provider Name (Legal Business Name): LYDIA WILLIS WHITE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LYDIA WILLIS

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5838 HARBOUR VIEW BLVD STE 100
SUFFOLK VA
23435-2663
US

IV. Provider business mailing address

PO BOX 639971
CINCINNATI OH
45263-9971
US

V. Phone/Fax

Practice location:
  • Phone: 757-673-5680
  • Fax: 757-483-3075
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009295
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: